Know Your Naloxone: Save a Life
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on May 5, 2021.
The Opioid Overdose Reality
Over 50,000 Americans died from an opioid overdose in 2019, based on the latest data from NIDA. That equates to almost 6 people dying every hour of every day. It's a tragedy, but there are ways we can help.
Opioids are a class of drugs that include narcotic analgesic prescription medications such as:
- oxycodone (Oxycontin)
- hydrocodone (Hysingla ER, Zohydro ER)
- acetaminophen and hydrocodone (Vicodin, Lortab, Norco)
- fentanyl (Actiq, Durgesic, Lazanda)
In the US, the death rate from prescription opioid overdoses has increased over 4-fold since 1999, while deaths from heroin deaths have more than quadrupled since 2010. Opioid overdoses include prescription opioids like oxycodone, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid.
Heroin, an illegal and highly addictive drug, is increasingly found on the streets contaminated with fentanyl, often smuggled in from China and Mexico.
In July 2020 the FDA urged doctors to discuss and possibly prescribe naloxone with all patients and caregivers when they are prescribed opioids for pain or for opioid use disorder.
- This recommendation is now required on the prescribing information for these medicines.
- This recommendation is especially important for patients who are at increased risk of opioid overdose, such as patients also using benzodiazepines or other medicines that depress the central nervous system, who have a history of opioid use disorder (OUD), or who have experienced a previous opioid overdose.
How Do I Recognize an Opioid Overdose?
All opioids (narcotics) will produce various levels of central nervous system (CNS) depression and side effects such as drowsiness, sedation, and slowed breathing.
- In an overdose, you might notice stupor, coma, slurred speech, clammy skin, pinpoint pupils, and low blood pressure.
- The most dangerous and often fatal side effect of an opioid overdose is respiratory depression - slowed or arrested (stopped) breathing.
- This risk is multiplied when the narcotic is combined with alcohol or other CNS depressants like benzodiazepines.
If you believe someone has overdosed on narcotics, call 911 immediately. A reversal agent called naloxone can be life-saving for patients who overdose on narcotics, although in patients dependent upon opioids, it can also cause a severe withdrawal effect. If you have access to naloxone (Narcan) administer it to the person first, then immediately call 911.
What is Naloxone?
Naloxone is a medication that rapidly reverses the effects of an opioid (narcotic) overdose and is the standard treatment.
Naloxone has been available in injection form to reverse the effects of opioid overdose for more than 40 years. It is not addictive or considered an opioid itself. Prior naloxone treatments required administration via a syringe and needle and were most commonly used by trained medical personnel and emergency responders.
Today, newer naloxone approvals come as nasal sprays to make this life-saving drugs more user-friendly.
In fact, most states have now passed legislation designed to improve lay-person naloxone access.
How Can Naloxone Save a Life?
Meically speaking, naloxone is considered an opioid antagonist, meaning it blocks opioid receptors found in our bodies.
- Unlike opioids, naloxone is not a controlled substance and has no potential for abuse.
- In fact, naloxone has no action in the absence of an actual opioid overdose. Naloxone will not hurt someone who does not have opioids in their system. It is regularly used by first responders and can be administered by lay-people with little or no training.
- Brand names include Narcan Nasal and Kloxxado
Naloxone can counter overdose effects, including depressed breathing, drowsiness, and loss of consciousness - usually within 2 to 3 minutes - and can be given by family members or caregivers until emergency help arrives.
For families or friends that elect to carry the devices or store these medications in their home, learning how to use them ahead of time may save time.
What Are Opioids?
Naloxone reverses the effects of prescription opioid overdoses, as well as heroin, but has no action in other types of overdoses such as benzodiazepines like alprazolam (Xanax) or lorazepam (Ativan), sedatives like barbiturates, or alcohol.
You should always call for emergency help when you use naloxone; you may not know what the person has overdosed on, and it may be a mixture of substances. Examples of prescription opioids that may be involved in an overdose include:
- buprenorphine (Buprenex)
- buprenorphine transdermal system (Butrans Skin Patch)
- fentanyl (Actiq, Duragesic, Fentora)
- hydrocodone (Hysingla ER, Zohydro ER)
- hydromorphone (Dilaudid)
- meperidine (Demerol)
- methadone (Methadose)
- morphine (Kadian, MS Contin)
- oxycodone (Percocet, Percodan, Oxaydo, OxyContin, Roxicodone)
- tapentadol (Nucynta, Nucynta ER)
- tramadol (Conzip, Qdolo, Ultram)
If drugs have been purchased on the street, they could contain added narcotics, benzodiazepines, or other unknown toxic chemicals.
Narcan: The Original
The first FDA-approved naloxone was injectable Narcan which became available in the early 1970's. Brand name injectable Narcan is now discontinued, but the generic is available.
- The intravenous formulation is used in clinic and hospital settings, but an intramuscular formulation is available also, often sold in a kit with 2 syringes and 2 vials of 0.4 mg/mL naloxone and provided to emergency first-responders.
- The naloxone vials are also sold in a kit with nasal atomizers for use as a nasal spray. All kits contain an instruction chart for use and assembly direction.
- The FDA-approved Narcan Nasal Spray is available at pharmacies in the U.S.
- In 2020, a generic version of Narcan Nasal Spray, known as naloxone nasal spray from Paddock Labs, was tentatively approved by the FDA but may not yet be on shelves. Speak with your pharmacist for availability.
Patients who cannot afford these branded medications should call the US manufacturer to determine if they qualify for assistance or if other pricing discounts or coupons are possible.
Evzio (naloxone hydrochloride) Autoinjector is now discontinued
Evzio autoinjector, and its authorized generic from Kaleo have now been discontinued from the US market.
In April 2014 the FDA approved Evzio (naloxone hydrochloride) as an emergency treatment for known or suspected opioid overdose.
- Evzio delivered a single naloxone dose via a hand-held auto-injector that could be carried in a pocket or stored in a medicine cabinet in a caregiver's home.
- When Evzio was turned on, it provided verbal instructions to the user. This was an advantage in a stressful, emergency situation that a lay-person might encounter.
Narcan Nasal Spray: A User-Friendly Option
In November 2015 Narcan Nasal Spray 4 mg became available as the first FDA-approved nasal spray version of naloxone. The 2 mg spray has now been discontinued.
Narcan Nasal offers an advantage to the lay-person. It is user-friendly and is easily carried in a purse or pocket or stored in the home.
In clinical studies, one dose of Narcan Nasal 4 mg resulted in similar levels to intramuscular (IM) injected naloxone 0.4 mg/mL and at roughly the same time.
How to Use Narcan Nasal Spray
Narcan Nasal Spray can be used for adults or children. The drug is sprayed into one nostril while the person is lying on their back. If naloxone is administered quickly, it can counter the overdose effects, usually within minutes.
Fully review directions enclosed in the box when you receive the medication; do not wait until an emergent situation.
- Remove the Narcan Nasal Spray from box. DO NOT prime the device before administering. Place your thumb on the plunger bottom and your first and middle fingers on either side of nozzle.
- Tilt the person’s head back and provide neck support with your hand.
- Gently insert the nozzle tip in one nostril until your fingers on either side of the nozzle are against the bottom of the person’s nose. Press the plunger firmly to give the full dose.
- Get emergency medical help right away after giving the first dose of Narcan Nasal Spray. Rescue breathing or CPR may be given while waiting for emergency medical help.
- If symptoms return, give another dose in the other nostril after 2 to 3 minutes using a new Narcan Nasal Spray in alternate nostrils with each dose until emergency medical assistance arrives.
Naloxone Side Effects
Common naloxone side effects may include symptoms of opioid withdrawal such as:
- anxiety or agitation
- nausea or vomiting
- runny nose
- high blood pressure
Acute withdrawal from chronic opioid use may also result in seizures, pain, and elevated heart rate.
While naloxone will reverse some, but not all, symptoms caused by a tramadol (Ultram, ConZip) overdose, the risk of seizures is also increased and may require treatment with an anti-seizure medication.
Reversal of the slowed or stopped breathing due to some opioids may not be complete when Narcan is used (like partial agonists or mixed agonists/antagonists, such as buprenorphine). Larger or repeat naloxone doses may be required. Call 911 immediately after you administer the first dose to anyone who has had an overdose.
Opioid Withdrawal Symptoms
In patients who are dependent on opioids, withdrawal symptoms can occur suddenly after they receive naloxone.
Abrupt opioid withdrawal symptoms may include:
- Body aches, diarrhea, increased heart rate
- Fever, runny nose, sneezing
- Goose bumps
- Sweating, yawning, nausea or vomiting
- Nervousness, restlessness or irritability
- Shivering, trembling
- Stomach cramping, weakness, increased blood pressure
Discuss Naloxone with Your Doctor
Opioid painkillers and medicines used to treat opioid use disorder (OUD) must now include information about naloxone use and prescribing. Patients and healthcare professionals should review these latest recommendations.
The FDA now recommends that healthcare providers discuss and offer naloxone when prescribing opioids to patients at an increased risk of overdose, including:
- patients who are also taking benzodiazepines or other drugs that suppress the central nervous system
- patients with a history of overdose on opioids
- those with a history of opioid use disorder (OUD)
- when a patient has household members, including children, or other close contacts at risk for accidental ingestion or opioid overdose.
- consider prescribing naloxone to patients not receiving a prescription for an opioid analgesic or medicine to treat OUD if they are at increased risk of opioid overdose.
These discussions should occur both when beginning and renewing treatment.
Sublocade: An Option for Opiate Dependence
While Narcan can save a life from an overdose, a multi-pronged treatment plan is needed to rescue patients from chronic misuse of opioids.
Sublocade (buprenorphine) is available as a once-monthly injectable partial opioid agonist formulation for the treatment of opioid use disorder (OUD). Sublocade, from Indivior, was FDA-approved in November 2017.
Sublocade is an extended-release subcutaneous (under the skin) injection that steadily releases buprenorphine into your bloodstream to treat OUD over a one-month period.
Sublocade is only given by a healthcare provider. Serious harm or death could result if administered intravenously.
Kloxxado Approved: A Higher Dose Naloxone Nasal Spray
In April 2021, Kloxxado (naloxone nasal spray) from Hikma Pharmaceuticals was approved to treat known or suspected opioid overdoses in adults and children. Like Narcan Nasal, it is not a substitute for emergency medical care.
Kloxxado nasal spray contains 8 mg per spray, which is double the amount in Narcan Nasal. And like Narcan Nasal, extra doses may be given if the person remains unresponsive while waiting for emergency medical assistance to arrive. Extra doses of naloxone are often required in the emergency opioid overdose situation.
Side effects noted in the packge label include: stomach pain, asthenia (weakness), dizziness, headache, nasal discomfort, and lightheadedness (feeling like you are going to faint).
Hikma expects Kloxxado to be commercailly available in the second half of 2021.
The Path Forward in Saving Lives
Prescription opioid drug addiction is a domestic threat unlike any other in the US. Concerted efforts from family, friends, health care providers, first-responders, and patients themselves are needed to combat this epidemic.
- New, more user-friendly antidotes to reverse an opioid overdose are available, but accessibility for all parties is needed.
- Patients and caregivers should discuss with their healthcare provider if the quick availability of a naloxone product makes sense in their situation, before an emergency occurs. Individual medical advice should always come from your healthcare provider.
- To keep up-to-date with the latest news, or to voice questions or concerns, consider joining the Opiate Dependence Support Group on Drugs.com.
Finished: Know Your Naloxone: Save a Life
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- FDA Requiring Labeling Changes for Opioid Pain Medicines, Opioid Use Disorder Medicines Regarding Naloxone. US Food and Drug Administration. Accessed May 5, 2021 at https://www.fda.gov/news-events/press-announcements/fda-requiring-labeling-changes-opioid-pain-medicines-opioid-use-disorder-medicines-regarding
- Opioid Overdose Crisis. National Institute of Drug Abuse (NIDA). Jan. 2019. Accessed May 5, 2021 at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
- CDC Guideline for Prescribing Opioids for Chronic Pain. Centers for Disease Control and Prevention (CDC). Accessed May 5, 2021 at https://www.cdc.gov/drugoverdose/pdf/Guidelines_At-A-Glance-a.pdf
- Centers for Disease Control and Prevention (CDC). Injury Prevention & Control: Opioid Overdose. Data Overview. Accessed May 5, 2021 at https://www.cdc.gov/drugoverdose/data/index.html
- Evzio Instructions for Use. Drugs.com. Accessed August 25, 2020 at https://www.drugs.com/pro/evzio.html#ABIFU
- Narcan Nasal Spray Prescribing Information. Revised 8/2020. Accessed May 5, 2021 at http://www.narcannasalspray.com/pdf/NARCAN-Prescribing-Information.pdf